Provider Demographics
NPI:1154534857
Name:GLENN, CHARLES EDWARD (MA, MFT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:GLENN
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 CARLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-5113
Mailing Address - Country:US
Mailing Address - Phone:310-635-5179
Mailing Address - Fax:310-537-7136
Practice Address - Street 1:3530 LONG BEACH BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3942
Practice Address - Country:US
Practice Address - Phone:310-635-5179
Practice Address - Fax:310-537-7136
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 09280106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist